Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

Analgesic comparison between perineural and intravenous dexamethasone for shoulder arthroscopy: a meta-analysis of randomized controlled trials

Journal of Orthopaedic Surgery and Research volume 17, Article number: 103 (2022) Cite this article

Abstract

Introduction

The analgesic comparison between perineural and intravenous dexamethasone on interscalene block for pain management after shoulder arthroscopy remains controversial. We conduct this meta-analysis to explore the influence of perineural versus intravenous dexamethasone on interscalene block for pain control after shoulder arthroscopy.

Methods

We have searched PubMed, Embase, Web of science, EBSCO and Cochrane library databases through April 2021 and included randomized controlled trials (RCTs) assessing the effect of perineural and intravenous dexamethasone on interscalene block in patients with shoulder arthroscopy.

Results

Five RCTs were included in the meta-analysis. Overall, compared with intravenous dexamethasone for shoulder arthroscopy, perineural dexamethasone led to similar block duration (SMD = 0.12; 95% CI − 0.12 to 0.35; P = 0.33), pain scores at 12 h (SMD = − 0.67; 95% CI − 1.48 to 0.15; P = 0.11), pain scores at 24 h (SMD = − 0.33; 95% CI − 0.79 to 0.14; P = 0.17), opioid consumption (SMD = 0.01; 95% CI − 0.18 to 0.19; P = 0.95) and incidence of nausea/vomiting (OR = 0.74; 95% CI 0.38–1.44; P = 0.38).

Conclusions

Perineural and intravenous dexamethasone demonstrated comparable pain relief after shoulder arthroscopy.

Introduction

Arthroscopy has been widely accepted to diagnose and treat shoulder diseases [1,2,3]. However, significant postoperative pain is the main concern after this surgery and effective analgesia is required for this day-case surgery [3,4,5]. Interscalene brachial plexus block (ISB) is the standard analgesia after shoulder surgery with the features of superior analgesia and reduced opioid consumption [6,7,8]. ISB is limited by short analgesic maintenance for several hours, and especially moderate to severe pain of this surgery requires opioid supplementation [9].

The increase in the dose of local anesthetic is used to prolong ISB, but has the limitation of narrow therapeutic window and volume/concentration. Volumes of 10 ml or greater injected into the interscalene groove can increase the risk of ipsilateral hemi-diaphragmatic paresis [10]. Several anesthetics have been developed to prolong ISB. In particular, dexamethasone used by perineural approach showed the potential in prolonging the duration of peripheral nerve blocks when in conjunction with local anesthetics [11].

Recently, several studies have compared the analgesic efficacy between perineural with intravenous dexamethasone for the pain management after shoulder arthroscopy, but the results are conflicting [10, 12, 13]. With accumulating evidence, we therefore perform this meta-analysis of RCTs to compare perineural with intravenous dexamethasone for shoulder arthroscopy.

Materials and methods

Ethical approval and patient consent were not required because this was a meta-analysis of previously published studies. We conducted this meta-analysis in adherence to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [14, 15].

Search strategy and study selection

Two investigators have independently searched the following databases (inception to April 2021): PubMed, Embase, Web of science, EBSCO and Cochrane library databases. The electronic search strategy was conducted using the following keywords: “dexamethasone” AND “interscalene block” AND “shoulder arthroscopy.” We also checked the reference lists of the screened full-text studies to identify other potentially eligible trials.

The inclusive selection criteria were as follows: (i) patients underwent shoulder arthroscopy; (ii) intervention treatments were perineural versus intravenous dexamethasone as the adjunctive therapy to interscalene block; (iii) study design was RCT.

Data extraction and outcome measures

We extracted the following information: author, number of patients, age, female, body weight, American Society of Anesthesiologists (ASA) physical status and detail methods in each group etc. Data were extracted independently by two investigators, and discrepancies were resolved by consensus. We also contacted the corresponding author to obtain the data when necessary. The primary outcome was block duration. Secondary outcomes included pain scores at 12 h, pain scores at 24 h, opioid consumption, and the incidence of nausea/vomiting.

Quality assessment in individual studies

Methodological quality of the included studies was independently evaluated using the modified Jadad scale [16]. There were three items for Jadad scale: randomization (0–2 points), blinding (0–2 points) and dropouts and withdrawals (0–1 points). The score of Jadad Scale varied from 0 to 5 points. An article with Jadad score ≤ 2 was considered to be of low quality, while Jadad score ≥ 3 suggested high quality [17].

Statistical analysis

We estimated the standard mean difference (SMD) with 95% confidence interval (CI) for continuous outcomes (block duration, pain scores at 12 h, pain scores at 24 h and opioid consumption) and odd ratios (ORs) with 95% CIs for dichotomous outcomes (nausea/vomiting). The random-effects model was used regardless of heterogeneity. Heterogeneity was reported using the I2 statistic, and I2 > 50% indicated significant heterogeneity [15, 18]. We searched for potential sources of heterogeneity via omitting one study in turn for the meta-analysis or performing subgroup analysis. All statistical analyses were performed using Review Manager version 5.3 (The Cochrane Collaboration, Software Update, Oxford, UK).

Results

Literature search, study characteristics and quality assessment

Figure 1 demonstrates the detailed flowchart of the search and selection results. Initially, 78 potentially relevant articles were identified and five RCTs were finally included in the meta-analysis [10, 12, 13, 19, 20]. The baseline characteristics of five eligible RCTs in the meta-analysis are summarized in Table 1. The five studies were published between 2016 and 2020, and total sample size was 585.

Fig. 1
figure 1

Flow diagram of study searching and selection process

Full size image
Table 1 Characteristics of included studies
Full size table

The doses of perineural or intravenous dexamethasone ranged from 1 to 5 mg, and the concentrations of perineural dexamethasone varied from 0.1333 mg/ml to 1 mg/ml. Among the five studies included here, three studies reported block duration [10, 12, 13], three studies reported pain scores at 12 h [10, 19, 20], four studies reported pain scores at 24 h [10, 12, 19, 20], three studies reported opioid consumption [10, 12, 13], and three studies reported nausea/vomiting [10, 19, 20]. Jadad scores of the five included studies varied from 3 to 5, and all five studies had high quality according to quality assessment.

Primary outcome: block duration

These outcome data were analyzed with the random-effects model, and compared to intravenous dexamethasone for shoulder arthroscopy, perineural dexamethasone resulted in comparable duration of sufficient analgesia, as evidenced by similar block duration (SMD = 0.12; 95% CI − 0.12 to 0.35; P = 0.33) with low heterogeneity among the studies (I2 = 37%, heterogeneity P = 0.33) (Fig. 2).

Fig. 2
figure 2

Forest plot for the meta-analysis of block duration

Full size image

Sensitivity analysis

Low heterogeneity was observed among the included studies for the primary outcome, so we did not perform sensitivity analysis via omitting one study in turn to detect the heterogeneity.

Secondary outcomes

In comparison with intravenous dexamethasone for shoulder arthroscopy, perineural dexamethasone exhibited comparable control of pain intensity shown by pain scores at 12 h (SMD = − 0.67; 95% CI − 1.48 to 0.15; P = 0.11; Fig. 3) and 24 h (SMD = − 0.33; 95% CI − 0.79 to 0.14; P = 0.17; Fig. 4). In addition, these two approaches of dexamethasone resulted in similar opioid consumption (SMD = 0.01; 95% CI − 0.18 to 0.19; P = 0.95; Fig. 5) and the incidence of nausea/vomiting (OR = 0.74; 95% CI 0.38–c1.44; P = 0.38; Fig. 6).

Fig. 3
figure 3

Forest plot for the meta-analysis of pain scores at 12 h

Full size image
Fig. 4
figure 4

Forest plot for the meta-analysis of pain scores at 24 h

Full size image
Fig. 5
figure 5

Forest plot for the meta-analysis of opioid consumption

Full size image
Fig. 6
figure 6

Forest plot for the meta-analysis of nausea/vomiting

Full size image

Discussion

Serious pain after shoulder arthroscopy commonly occurs and mainly results from the insertion of arthroscopic instruments into the joint, soft tissue dissection and distention [21,22,23,24,25]. Patients’ early mobilization and rehabilitation is significantly affected by this postoperative pain [26,27,28]. Numerous techniques have been studied, and ISB is widely accepted as the most effective analgesic technique for this surgery [3, 29,30,31]. Furthermore, supplementation with dexamethasone revealed a significant role in increasing the duration and analgesic efficacy of ISB for shoulder arthroscopy [13, 19].

Previous study comparing perineural and systemic dexamethasone showed that both routes were associated with prolonged and similar block duration [32,33,34]. In order to compare perineural with intravenous dexamethasone supplementation for ISB in patients with shoulder arthroscopy, our meta-analysis included five RCTs and revealed that perineural and intravenous dexamethasone resulted in comparable block duration, pain control and opioid consumption when in conjunction with local analgesics for shoulder arthroscopy. Dexamethasone is found to reduce ectopic neuronal discharge and inhibit potassium channel-mediated discharge of nociceptive C-fibers. Additionally, dexamethasone supplementation can provide superior analgesia in the context of peripheral nerve block through systemic anti-inflammatory effects [10, 35].

As shown in Fig. 3, considerable clinical heterogeneity is observed, and we searched for potential sources of heterogeneity via omitting one study in turn. After excluding the study conducted by McHardy et al. [10], we found that no heterogeneity remained and perineural dexamethasone resulted in lower pain scores at 12 h than intravenous dexamethasone (SMD = − 1.07; 95% CI − 1.43 to − 0.71; P < 0.00001). McHardy et al. reported the perineural dexamethasone at the concentration of 0.667 mg/ml [10], while other two studies reported the perineural dexamethasone at the concentration of 0.190 and 0.417 mg/ml [19, 20]. In addition, in Fig. 4, Kahn et al. reported perineural dexamethasone at the concentration of 1 mg/ml [12], and perineural dexamethasone at the concentration of 1 mg/ml and 0.667 mg/ml can obtain the comparable analgesic efficacy than intravenous dexamethasone. These indicated that the lower concentration of perineural dexamethasone (≤ 0.417 mg/ml) produced substantially lower analgesic efficacy than intravenous dexamethasone for shoulder arthroscopy, and higher concentration of perineural dexamethasone (≥ 0.667 mg/ml) and intravenous dexamethasone had comparable analgesic efficacy, suggesting that concentrations of perineural dexamethasone were crucial for the analgesic efficacy of interscalene block in patients with shoulder arthroscopy.

In addition, the incidence of nausea/vomiting was similar between two groups based on our results. This meta-analysis also has several limitations. Firstly, our analysis is based on five RCTs, and two of them have a relatively small sample size (n < 100). Overestimation of the treatment effect is more likely in smaller trials compared with larger samples. Next, different concentrations and combination methods of dexamethasone may produce some bias. Finally, it is not feasible to perform the meta-analysis of some important index such as discharge time and time to first analgesic requirement based on current RCTs.

Conclusions

Perineural and intravenous dexamethasone showed similar efficacy for block duration after shoulder arthroscopy.

Availability of data and materials

Not applicable.

Abbreviations

RCTs:

Randomized controlled trials

MDs:

Mean differences

CIs:

Confidence intervals

RRs:

Risk ratios

References

  1. Cabaton J, Nové-Josserand L, Mercadal L, Vaudelin T. Analgesic efficacy of ultrasound-guided interscalene block vs. supraclavicular block for ambulatory arthroscopic rotator cuff repair: a randomised noninferiority study. Eur J Anaesthesiol. 2019;36(10):778–86.

    Article  Google Scholar 

  2. Burkhart SS. Shoulder arthroscopy: a bridge from the past to the future. J Shoulder Elbow Surg. 2020;29(8):e287–96.

    Article  Google Scholar 

  3. Warrender WJ, Syed UAM, Hammoud S, Emper W, Ciccotti MG, Abboud JA, Freedman KB. Pain management after outpatient shoulder arthroscopy: a systematic review of randomized controlled trials. Am J Sports Med. 2017;45(7):1676–86.

    Article  Google Scholar 

  4. Uquillas CA, Capogna BM, Rossy WH, Mahure SA, Rokito AS. Postoperative pain control after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2016;25(7):1204–13.

    Article  Google Scholar 

  5. Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia. 2010;65(6):608–24.

    Article  CAS  Google Scholar 

  6. Lee JH, Cho SH, Kim SH, Chae WS, Jin HC, Lee JS, Kim YI. Can J Anaesth = Journal canadien d’anesthesie. 2011;58(11):1001–6.

    Article  Google Scholar 

  7. Zhai W, Wang X, Rong Y, Li M, Wang H. Effects of a fixed low-dose ropivacaine with different volume and concentrations on interscalene brachial plexus block: a randomized controlled trial. BMC Anesthesiol. 2016;16(1):80.

    Article  Google Scholar 

  8. Sinha SK, Abrams JH, Barnett JT, Muller JG, Lahiri B, Bernstein BA, Weller RS. Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med. 2011;36(1):17–20.

    Article  CAS  Google Scholar 

  9. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Anesth Analg. 2015;120(5):1114–29.

    Article  Google Scholar 

  10. McHardy PG, Singer O, Awad IT, Safa B, Henry PDG, Kiss A, Au SK, Kaustov L, Choi S. Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial. Br J Anaesth. 2020;124(1):84–91.

    Article  CAS  Google Scholar 

  11. Albrecht E, Kern C, Kirkham KR. A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks. Anaesthesia. 2015;70(1):71–83.

    Article  CAS  Google Scholar 

  12. Kahn RL, Cheng J, Gadulov Y, Fields KG, YaDeau JT, Gulotta LV. Perineural low-dose dexamethasone prolongs interscalene block analgesia with bupivacaine compared with systemic dexamethasone: a randomized trial. Reg Anesth Pain Med. 2018;43(6):572–9.

    Article  CAS  Google Scholar 

  13. Holland D, Amadeo RJJ, Wolfe S, Girling L, Funk F, Collister M, Czaplinski E, Ferguson C, Leiter J, Old J, MacDonald P, Dufault B, Mutter TC. Effect of dexamethasone dose and route on the duration of interscalene brachial plexus block for outpatient arthroscopic shoulder surgery: a randomized controlled trial. Can J Anaesth = Journal canadien d’anesthesie. 2018;65(1):34–45.

    Article  Google Scholar 

  14. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006–12.

    Article  Google Scholar 

  15. Zhao J, Huang W, Zhang S, Xu J, Xue W, He B, Zhang Y. Efficacy of glutathione for patients with cystic fibrosis: a meta-analysis of randomized-controlled studies. Am J Rhinol Allergy. 2019. https://doi.org/10.1177/1945892419878315.

    Article  PubMed  Google Scholar 

  16. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, Gavaghan DJ, McQuay HJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1–12.

    Article  CAS  Google Scholar 

  17. Kjaergard LL, Villumsen J, Gluud C. Reported methodologic quality and discrepancies between large and small randomized trials in meta-analyses. Ann Intern Med. 2001;135(11):982–9.

    Article  CAS  Google Scholar 

  18. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.

    Article  Google Scholar 

  19. Sakae TM, Marchioro P, Schuelter-Trevisol F, Trevisol DJ. Dexamethasone as a ropivacaine adjuvant for ultrasound-guided interscalene brachial plexus block: a randomized, double-blinded clinical trial. J Clin Anesth. 2017;38:133–6.

    Article  CAS  Google Scholar 

  20. Chun EH, Kim YJ, Woo JH. Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? Intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial. Medicine. 2016;95(23):e3828.

    Article  CAS  Google Scholar 

  21. Botser IB, Smith TW Jr, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy. 2011;27(2):270–8.

    Article  Google Scholar 

  22. Li C, Qu J. Efficacy of dexmedetomidine for pain management in knee arthroscopy: a systematic review and meta-analysis. Medicine. 2017;96(43):e7938.

    Article  CAS  Google Scholar 

  23. Tepolt FA, Bido J, Burgess S, Micheli LJ, Kocher MS. Opioid overprescription after knee arthroscopy and related surgery in adolescents and young adults. Arthroscopy. 2018. https://doi.org/10.1016/j.arthro.2018.07.021.

    Article  PubMed  Google Scholar 

  24. Tong D, Chung F. Postoperative pain control in ambulatory surgery. Surg Clin N Am. 1999;79(2):401–30.

    Article  CAS  Google Scholar 

  25. Chen X, Mou X, He Z, Zhu Y. The effect of midazolam on pain control after knee arthroscopy: a systematic review and meta-analysis. J Orthop Surg Res. 2017;12(1):179.

    Article  Google Scholar 

  26. Nicholson T, Maltenfort M, Getz C, Lazarus M, Williams G, Namdari S. Multimodal pain management protocol versus patient controlled narcotic analgesia for postoperative pain control after shoulder arthroplasty. Arch Bone Joint Surg. 2018;6(3):196.

    PubMed  PubMed Central  Google Scholar 

  27. Jung HS, Seo KH, Kang JH, Jeong J-Y, Kim Y-S, Han N-R. Optimal dose of perineural dexmedetomidine for interscalene brachial plexus block to control postoperative pain in patients undergoing arthroscopic shoulder surgery: a prospective, double-blind, randomized controlled study. Medicine. 2018;97(16):e0440.

    Article  CAS  Google Scholar 

  28. Calvo E, Torres MD, Morcillo D, Leal V. Rotator cuff repair is more painful than other arthroscopic shoulder procedures. Arch Orthop Trauma Surg. 2019;139(5):669–74.

    Article  Google Scholar 

  29. Ullah H, Samad K, Khan FA. Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery. Cochrane Database Syst Rev. 2014;2014(2):Cd007080.

    PubMed Central  Google Scholar 

  30. Hortense A, Perez MV, Amaral JL, Oshiro AC, Rossetti HB. Interscalene brachial plexus block. Effects on pulmonary function. Rev Bras Anestesiol. 2010;60(2):130–7.

    Article  Google Scholar 

  31. Stundner O, Meissnitzer M, Brummett CM, Moser S, Forstner R, Koköfer A, Danninger T, Gerner P, Kirchmair L, Fritsch G. Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: a randomized, controlled trial. Br J Anaesth. 2016;116(3):405–12.

    Article  CAS  Google Scholar 

  32. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J, Pottel H, Carlier S, Missant C, Van de Velde M. IV and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. Br J Anaesth. 2013;111(3):445–52.

    Article  CAS  Google Scholar 

  33. Abdallah FW, Johnson J, Chan V, Murgatroyd H, Ghafari M, Ami N, Jin R, Brull R. Intravenous dexamethasone and perineural dexamethasone similarly prolong the duration of analgesia after supraclavicular brachial plexus block: a randomized, triple-arm, double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2015;40(2):125–32.

    Article  CAS  Google Scholar 

  34. Rosenfeld DM, Ivancic MG, Hattrup SJ, Renfree KJ, Watkins AR, Hentz JG, Gorlin AW, Spiro JA, Trentman TL. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 2016;71(4):380–8.

    Article  CAS  Google Scholar 

  35. Attardi B, Takimoto K, Gealy R, Severns C, Levitan ES. Glucocorticoid induced up-regulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors Channels. 1993;1(4):287–93.

    CAS  PubMed  Google Scholar 

Download references

Acknowledgements

None.

Funding

Not applicable.

Author information

Author notes

  1. Liangku Huang and Peng Li contributed equally to this study

Authors and Affiliations

  1. Department of Hand Surgery, Xi’an Honghui Hospital, Xi’an Jiaotong University Health Science Center, Xi’an, 710054, Shaanxi, China

    Liangku Huang, Peng Li & Guangming Kang

  2. Department of Orthopaedic Oncology, Xi’an Honghui Hospital, Xi’an Jiaotong University Health Science Center, Xi’an, 710054, Shaanxi, China

    Haizhen Zhou

  3. Sports Medicine Center, Xi’an Honghui Hospital, Xi’an Jiaotong University Health Science Center, No. 555 Youyidong Street, Beilin District, Xi’an, 710054, Shaanxi, China

    Liang Zhang & Zandong Zhao

Authors
  1. Liangku Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peng Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Liang Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Guangming Kang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Haizhen Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Zandong Zhao
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

LH and PL conducted the design, study planning, data analysis and data interpretation. LH, PL, HZ and ZZ wrote and revised the article. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Zandong Zhao.

Ethics declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huang, L., Li, P., Zhang, L. et al. Analgesic comparison between perineural and intravenous dexamethasone for shoulder arthroscopy: a meta-analysis of randomized controlled trials. J Orthop Surg Res 17, 103 (2022). https://doi.org/10.1186/s13018-022-02952-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13018-022-02952-6

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X